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VOL 53, NO 3, SUPPL 2

MARCH 2009

Vol53,No3,Suppl2,

March2009,PagesS1S124

Saundersan Imprint of Elsevier

Supplement to

KDOQI Clinical Practice Guideline for

Nutrition in Children with CKD:

2008 Update


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Abstract

The 2008 update of the Kidney Disease Outcomes Quality Initiative (KDOQI) pediatric nutrition

clinical practice guideline is intended to assist the practitioner caring for infants, children, and

adolescents with chronic kidney disease (CKD) stages 2 to 5, on long-term dialysis therapy, or with akidney transplant. The guideline contains recommendations for evaluation of nutritional status andgrowth and for counseling and selecting nutrition therapies that are appropriate to age and CKD stage.Therapeutic interventions considered include enteral feeding, intradialytic parenteral nutrition, growthhormone therapy, and restriction or supplementation of various macro- and micronutrients. The WorkGroup drafted narrative reviews based on its expertise and knowledge of the literature in the field andused references to support its write-up. Given the heterogeneity and often unique circumstances of thedisease conditions in children with CKD, the Work Group adopted a perspective of issuing recommen-

dations of potential use for improving patient survival, health, and quality of life. The recommendationsalso underwent both internal and external review. Tables of food and formula nutrient content,procedures for anthropometric measurements, copies of growth charts, and a list of resources forcalculating energy requirements and anthropometric z scores are provided to assist with implementa-tion. Furthermore, limitations to the recommendations are discussed; comparisons to other guidelines

are made; and recommendations are provided for future research.

INDEXWORDS: Infants; children and adolescents; chronic kidney disease; dialysis; kidney transplan-

tation; nutrition; guideline.

American Journal of Kidney Diseases,Vol 53, No 3, Suppl 2 (March), 2009: e1 e1


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KDOQI Clinical Practice Guideline for Nutrition inChildren with CKD: 2008 Update

S1 Tables

S2 Figures

S3 Abbreviations andAcronyms

S5 Glossaryof Definitions

S6 Reference Key

S7 WorkGroupMembership

S8 KDOQIAdvisory BoardMembers

S9 Foreword

S11 Executive Summary

RECOMMENDATIONS

S16 Recommendation 1: Evaluation ofGrowthandNutritionalStatus

S27 Recommendation2:Growth

S31 Recommendation 3:NutritionalManagement andCounseling

S35 Recommendation 4: EnergyRequirements andTherapy

S48 Recommendation 5: Protein Requirements andTherapy

S53 Recommendation 6:Vitamin andTrace ElementRequirements andTherapy

CONTENTSVOL 53, NO 3,SUPPL 2,MARCH 2009

Continued


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S61 Recommendation 7: BoneMineral andVitamin DRequirements andTherapy

S70 Recommendation 8: Fluid andElectrolyteRequirements andTherapy

S75 Recommendation9: Carnitine

S77 Recommendation 10:NutritionalManagement of TransplantPatients

APPENDICES

S84 Appendix 1: Procedures forMeasuringGrowthParameters

S86 Appendix 2: Resources forCalculating AnthropometricSDS/Percentiles, Energy Requirements, andMidparentalHeight

S87 Appendix 3:Nutrient Content Information

S91 Appendix4: Initiating andAdvancingTube Feedings

S92 Appendix 5: Clinical GrowthCharts

S101 Appendix 6: Description ofGuidelineDevelopmentProcess

WORK GROUP BIOGRAPHIES AND REFERENCES

S105 Biographical andDisclosure Information

S108 References

Contents, Continued


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NOTICE

SECTION I: USE OFTHE CLINICALPRACTICEGUIDELINE

This Clinical Practice Guideline document is based upon the best information available at the timeof publication. It is designed to provide information and assist decision making. It is not intended to

define a standard of care and should not be construed as one, nor should it be interpreted as

prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when clinicians take into account the

needs of individual patients, available resources, and limitations unique to an institution or a type of

practice. Every health care professional making use of these recommendations is responsible for

evaluating the appropriateness of applying them in the setting of any particular clinical situation. The

recommendations for research contained within this document are general and do not imply a

specific protocol.

SECTION II: DISCLOSURE

The National Kidney Foundation (NKF) makes every effort to avoid any actual or reasonably

perceived conflicts of interest that may arise as a result of an outside relationship or a personal,

professional, or business interest of a member of the Work Group.

All members of the Work Group are required to complete, sign, and submit a disclosure and

attestation form showing all such relationships that might be perceived or actual conflicts of interest.

This document is updated annually and information is adjusted accordingly. All reported information

is published in its entirety at the end of this publication in the Work Group members Biographical

and Disclosure Information section and is on file at the NKF.

In citing this document, the following format should be used: National Kidney Foundation. KDOQIClinical Practice Guideline for Nutrition in Children with CKD: 2008 Update. Am J Kidney Dis 53:S1-S124, 2009 (suppl 2).


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Tables

Table 1. Recommended Parameters and Frequency of Nutritional Assessment for Children

with CKD Stages 2 to 5 and 5D..................................................................................... S16

Table 2. Equations to Estimate Energy Requirements for Children at Healthy Weights............. S36Table 3. Equations to Estimate Energy Requirements for Children Ages 3 to 18 Years

Who Are Overweight..................................................................................................... S36

Table 4. Physical Activity Coefficients for Determination of Energy Requirements in

Children Ages 3 to 18 Years .......................................................................................... S37

Table 5. Nutrient Content or Infusion Rates of IDPN Reported From Small Pediatric

Cohorts .......................................................................................................................... S41

Table 6. Potential Adverse Occurrences with IDPN.................................................................... S41

Table 7. Acceptable Macronutrient Distribution Ranges ............................................................ S43

Table 8. Additional Recommendations on Specific Types of Fat and Carbohydrate .................. S43

Table 9. Dietary Treatment Recommendations for Children with Dyslipidemia and CKD

Stages 5, 5D, and Kidney Transplant............................................................................. S44

Table 10. Tips to Implement AHA Pediatric Dietary Guidelines for Prevention or

Treatment of Dyslipidemia and CVD in Prepubertal Children...................................... S44

Table 11. Dietary Modifications to Lower Serum Cholesterol and Triglycerides

for Adolescents with CKD............................................................................................. S45

Table 12. Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5

and 5D ........................................................................................................................... S49

Table 13. Average Ratio of Phosphorus to Protein Content in Various Protein-Rich Foods ......... S51

Table 14. Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake .... S54

Table 15. Physiological Effects and Sources of Vitamins ............................................................. S55

Table 16. Physiological Effects and Sources of Trace Elements................................................... S56

Table 17. Dietary Reference Intakes: Tolerable Upper Intake Levels........................................... S56

Table 18. Multivitamin Comparisons............................................................................................ S57

Table 19. Medicines and Other Substances Interfering with Vitamin B6and Folic Acid

Metabolism That May Contribute to Vitamin Deficiency ............................................. S57

Table 20. Recommended Calcium Intake for Children with CKD Stages 2 to 5 and 5D.............. S61

Table 21. Calcium Content of Common Calcium-Based Binders or Supplements....................... S62

Table 22. Recommended Supplementation for Vitamin D Deficiency/Insufficiency in

Children with CKD........................................................................................................ S65

Table 23. Recommended Maximum Oral and/or Enteral Phosphorus Intake for Children

with CKD....................................................................................................................... S67

Table 24. Target Range of Serum PTH by Stage of CKD ............................................................. S67

Table 25. Age-Specific Normal Ranges of Blood Ionized Calcium, Total

Calcium and Phosphorus ............................................................................................... S67

Table 26. DRI for Healthy Children for Water, Sodium, Chloride and Potassium........................ S71

Table 27. Insensible Fluid Losses.................................................................................................. S73

Table 28. Normal Serum Carnitine Levels (mol/L).................................................................... S75Table 29. Nutrition-Related Side-Effects of Immunosuppressive Medications ............................ S78

Table 30. Recommended Frequency of Measurement of Calcium, Phosphorus, PTH and

Total CO2 After Transplant............................................................................................ S81

Table 31. General Food Safety Recommendations for Immunosuppressed Children................... S82

Table 32. Resources for Calculating Anthropometric SDS and Percentiles.................................. S86

Table 33. Resources for Calculating Midparental Height ............................................................. S86

Table 34. Resources for Calculating Estimated Energy Requirements ......................................... S86

Table 35. Actual and Adjusted Amounts and Ratios of Phosphorus to Protein in Specific

Foods ............................................................................................................................. S87

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Table 36. Nutrient Content of Feeds and Supplements Used in Children with CKD.................... S88Table 37. Nutrient Content of Selected Foods High in Fiber ........................................................ S90Table 38. Suggested Rates for Initiating and Advancing Tube Feedings ...................................... S91

Table 39. KDIGO Nomenclature and Description for Rating Guideline Recommendations...... S102Table 40. Checklist for Guideline Reporting for the Update of the KDOQI PediatricNutrition Guideline...................................................................................................... S102

Figures

Figure 1. WHO Child Growth Standards: Boys length-for-age, birth to 2 years. ....................... S92

Figure 2. WHO Child Growth Standards: Girls length-for-age, birth to 2 years......................... S92Figure 3. WHO Child Growth Standards: Boys weight-for-age, birth to 2 years. ...................... S93Figure 4. WHO Child Growth Standards: Girls weight-for-age, birth to 2 years........................ S93Figure 5. WHO Child Growth Standards: Boys weight-for-length, birth to 2 years. .................. S94Figure 6. WHO Child Growth Standards: Girls weight-for-length, birth to 2 years. .................. S94Figure 7. WHO Child Growth Standards: Boys BMI-for-age, birth to 2 years........................... S95

Figure 8. WHO Child Growth Standards: Girls BMI-for-age, birth to 2 years........................... S95Figure 9. WHO Child Growth Standards: Boys head circumference-for-age, birth to 5 years. .. S96

Figure 10. WHO Child Growth Standards: Girls head circumference-for-age, birth to 5 years. .. S96Figure 11. CDC Clinical Growth Charts: Children 2 to 20 years, Boys stature-for-age

and weight-for-age. ...................................................................................................... S97Figure 12. CDC Clinical Growth Charts: Children 2 to 20 years, Girls stature-for-age

and weight-for-age....................................................................................................... S98Figure 13. CDC Clinical Growth Charts: Children 2 to 20 years, Boys BMI-for-age. ................. S99Figure 14. CDC Clinical Growth Charts: Children 2 to 20 years, Girls BMI-for-age................. S100

FiguresS2


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Abbreviations and Acronyms

ADL Activities of daily living

AHA American Heart Association

AI Adequate intake

AMDR Acceptable macronutrient distribution rangesAPD Automated peritoneal dialysis

BIA Bioelectrical impedance analysis

BMI Body mass index

BSA Body surface area

BUN Blood urea nitrogen

CAPD Continuous ambulatory peritoneal dialysis

CARI Caring for Australasians with Renal Impairment

CCPD Continuous cycler-assisted peritoneal dialysis

CDC Centers for Disease Control and Prevention

CKD Chronic kidney disease

CPD Chronic peritoneal dialysis

CVD Cardiovascular diseaseDHA Docosahexanoic acid

DPI Dietary protein intakes

DRI Dietary reference intake

DXA Dual-energy X-ray absorptiometry

DV Daily value

EAR Estimated average requirement

ECF Extracellular fluid

EER Estimated energy requirement

EPA Eicosapentanoic acid

ERT Evidence Review Team

G Urea generation rate

GFR Glomerular filtration rateHD Hemodialysis

HDL High-density lipoprotein

HPLC High-performance liquid chromatography

IDL Intermediate-density lipoprotein

IDPN Intradialytic parenteral nutrition

IgA Immunoglobulin A

IGF Insulin-like growth factor

K Potassium

KDIGO Kidney Disease: Improving Global Outcomes

KDOQI Kidney Disease Outcomes Quality InitiativeLDL Low-density lipoprotein

MAC Mid-arm circumference

MAMA Mid-arm muscle area

MAMC Mid-arm muscle circumference

MDRD Modification of Diet in Renal Disease

mRNA Messenger RNA

Na Sodium

NAPRTCS North American Pediatric Renal Trials and Collaborative Studies

ND Not determined

NE Nitrogen equivalent

n-3 FA Omega-3 fatty acids

NCEP-C National Cholesterol Expert Panel in Children and Adolescents



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NKF National Kidney FoundationnPCR Normalized protein catabolic ratenPNA Normalized protein nitrogen appearance

25(OH)D 25-Hydroxyvitamin D1,25(OH)2

D 1,25-Dihydroxyvitamin DPA Physical activity coefficient

PAL Physical activity levelPD Peritoneal dialysis

PEM Protein-energy malnutritionPET Peritoneal equilibration testPTH Parathyroid hormone

RDA Recommended Dietary AllowancerhGH Recombinant human growth hormone

SD Standard deviationSDS Standard deviation score(s)SGA Subjective Global Assessment

SGNA Subjective Global Nutrition AssessmentTEE Total energy expenditure

TG TriglyceridesTNA Total nitrogen appearanceTSF Triceps skinfold thickness

UL Tolerable upper intake levelUSDA US Department of AgricultureVLDL Very low-density lipoprotein

WHO World Health Organization

Abbreviations and AcronymsS4


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Glossary of Definitions

Acceptabl e Mac ronutr ien t Dis tribut ion Ran ges

(AMDR): A range of intake for each energy source

associated with reduced risk of chronic disease while

providing adequate intake of essential nutrients. The

AMDR is based on evidence that consumption greater

or less than these ranges may be associated with

nutrient inadequacy and increased risk of developing

chronic diseases, such as coronary heart disease, obe-

sity, diabetes, and/or cancer. The AMDR is expressed

as a percentage of total energy intake because its

requirementis not independent of other energy sources

or of the individuals total energy requirement.

Adequate Intake (AI): The recommended average

daily nutrient intake level based on observed or experi-

mentally determined approximations or estimates of

nutrient intake by a group (or groups) of apparentlyhealthy people who are assumed to be maintaining an

adequate nutritional state. The AI is expected to meet

or exceed the needs of most individuals in a specific

life-stage and gender group. When a Recommended

Dietary Allowance (RDA) is not available for a nutri-

ent, the AI can be used as the goal for usual intake by

an individual. The AI is not equivalent to an RDA.

Children: Infants, children, and adolescents be-

tween the ages of birth and 19 years.

Dietary Reference Intakes (DRI): Set of 4 nutrient-

based values that apply to the apparently healthy

general population consisting of RDA, Estimated

Average Requirement (EAR), AI, and TolerableUpper Intake Level (UL).

Enteral Nutrition*: Nutrition provided through the

gastrointestinal tract through a tube, catheter, or

stoma that delivers nutrients distal to the oral cavity.

Estimated Energy Requirement (EER): An EER is

defined as the average dietary energy intake that is

predicted to maintain energy balance in healthy nor-

mal-weight individuals of a defined age, sex, weight,

height, and level of physical activity consistent with

good health. In children, the EER includes the needs

associated with growth at rates consistent with good

health. Relative body weight (ie, loss, stable, or gain)

is the preferred indicator of energy adequacy.

Fiber: Combination ofdietary fiber, the edible non-

digestible carbohydrate and lignin components existing

naturally in plant foods, andfunctionalfiber,the isolated,

extracted, or synthetic fiber that has proven health ben-

efits. Fiber includes viscous or soluble forms that may

decrease serum cholesterol levels (eg, oat bran and

legumes/beans) and insoluble forms or bulking agents

that prevent or alleviate constipation (eg, wheat bran,

whole grains, vegetables, and fruits).

Height Age: The age at which the childs heightwould be on the 50th percentile.

Ideal Body Weight: The weight at the same per-centile as the childs height percentile, for the same

age and sex.

Macronutrients: Dietary fat, carbohydrate, pro-tein, and fiber.

Nutrition Care*: Interventions and counseling ofindividuals on appropriate nutrition intake through

the integration of information from the nutrition

assessment.

Nutrition Care Plan*: A formal statement of thenutrition goals and interventions prescribed for an

individual using the data obtained from a nutrition

assessment. The plan, formulated by an interdiscipli-

nary process, should include: statements of nutrition

goals and monitoring parameters, the most appropri-

ate route of administration of specialized nutrition

support (oral, enteral, and/or parenteral), method of

nutrition access, anticipated duration of therapy, and

training and counseling goals and methods.

Nutrition Therapy*: A component of medical treat-ment that includes oral, enteral, and parenteral nutrition.

Obesity: Body mass index (BMI) for age at 95thpercentile or greater.

Oral Nutrition*: Nutrition taken by mouth.Overweight: BMI for age at 85th or greater and

less than 95th percentiles.

Parenteral Nutrition*: The administration of nu-trients intravenously.

Physical Activity Level (PAL): The ratio of totalenergy expenditure (TEE) to basal energy expendi-

ture. PAL categories are defined as sedentary (PAL,

1.0 to 1.39), low active (PAL, 1.4 to 1.59), active

(PAL, 1.6 to 1.89), and very active (PAL, 1.9 to

2.5). PAL should not be confused with the physical

activity coefficient (PA values) used in the equa-

tions to estimate energy requirement.

Recommended Dietary Allowance (RDA): The in-take that meets the nutrient needs of almost all

(97% to 98%) individuals in a group. It may be

used as a goal for individual intake.Tolerable Upper Intake Level (UL): Thehighest av-erage daily nutrient intake level likely to pose no risk of

adverse health effects to almost all individuals in a given

life-stage and sex group. The UL is not a recommended

level of intake. As intake increases above the UL, the

potential risk of adverse effects increases.

* Source: Teitelbaum et al.1

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Reference Key

Stages of Chronic Kidney DiseaseStage Description GFR (mL/min/1.73 m2) Treatment

1 Kidney damage with normal or1 GFR 90

1-5T if kidney transplant recipient2 Kidney damage with mild2 GFR 60893 Moderate2GFR 30594 Severe2 GFR 15295 Kidney failure 15 (or dialysis) 5D if dialysis (HD or PD)

Abbreviations: CKD, chronic kidney disease; HD, hemodialysis; GFR, glomerular filtration rate; PD, peritoneal

dialysis;1, increased;2, decreased.

Nomenclature and Description for Rating Guideline Recommendations

Strength of the

Recommendation

Wording of the

Recommendation Prerequisite Assumption Expectation

A An intervention

should be

done

The quality of the evidence is

high or additional

considerations support a

strong recommendation

Most well-informed

individuals will

make the same

choice

The expectation is that the

recommendation will be

followed unless there

are compelling reasons

to deviate from it in an

individual. A strong

recommendation may

form the basis for a

clinical performance

measure

B An interventionshould be

considered

The quality of the evidence ishigh or moderate or

additional considerations

support a moderate

recommendation

A majority ofwell-informed

individuals will

make this

choice, but a

substantial

minority may not

The expectation is that therecommendation will be

followed in the majority

of cases

C An intervention is

suggested

The quality of the evidence is

moderate, low, or very

low or additional

considerations support a

weak recommendation

based predominantly on

expert judgment

A majority of

well-informed

individuals will

consider this

choice

The expectation is that

consideration will be

given to following the

recommendation

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KDOQI Clinical Practice Guideline forNutrition in Children with CKD

Work Group Membership

WorkGroupCo-Chairs

Bradley A. Warady, MD

Childrens Mercy Hospitals and Clinics

Kansas City, MO

Donna Secker, PhD, RD

The Hospital for Sick Children

Toronto, Canada

WorkGroup

Bethany Foster, MD

Montreal Childrens Hospital

Montreal, Canada

Stuart L. Goldstein, MD

Baylor College of Medicine

Houston, TX

Frederick Kaskel, MD, PhD

Childrens Hospital at Montefiore

Bronx, NY

Sarah E. Ledermann, MB

Great Ormond Street Hospital for Children

London, UK

Franz S. Schaefer, MD

Heidelberg University Hospital

Heidelberg, Germany

Nancy S. Spinozzi, RD, LDN

Childrens Hospital

Boston, MA

MethodsConsultants

Tufts Center for Kidney Disease Guideline Development and Implementation

at Tufts Medical Center, Boston, MA

Katrin Uhlig, MD, MS,Program Director, Nephrology

Ethan Balk, MD, MPH, Program Director, Evidence Based Medicine


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Foreword

The publication of the Kidney Disease Out-

comes Quality Initiative (KDOQI) Clini-

cal Practice Guideline for Nutrition in Children

with Chronic Kidney Disease: Update 2008 rep-

resents the first update of the K/DOQI Nutritionand Chronic Renal Failure guidelines that were

published in 2000.

The number of pediatric patients with chronic

kidney disease (CKD) continues to grow. Pa-

tients with CKD are at significant risk of protein-

energy malnutrition (PEM). Nutritional status in

these children is especially important because it

has a significant impact on linear growth, neuro-

cognitive development, and sexual development.

The effect of nutrition is especially important in

infants because deficits in either linear growth or

development that are acquired during infancymay not be fully correctable.

This guideline was developed to assist practi-

tioners in Pediatric Nephrology in assessing the

nutritional status of children with CKD, includ-

ing patients on dialysis therapy or who have a

kidney transplant; providing adequate macronu-

trient and micronutrient intake; and monitoring

and treating complications of CKD, including

bone mineral, vitamin D, fluid, and electrolyte

derangements. This guideline will be of great

importance to a broad audience of pediatric care-

givers who endeavor to mitigate the effects of

CKD on nutritional status and thus on the growth

and development of these children.

This guideline has been developed by involv-

ing multiple disciplines from both US and inter-

national sources. These perspectives have been

invaluable in ensuring a robust document with

broad perspective. Each statement is graded based

on the strength of recommendations (see the

Reference Key on page S6 and Appendix 6). As

for all KDOQI guidelines, these suggested inter-

ventions have been thoroughly discussed by all

members of the Work Group to ensure they

reflect state-of-the-art opinion on diagnosis, and

management of these nutritional disorders. This

final version of the document has undergonerevision in response to comments during the

public review process, an important and integral

part of the KDOQI guideline process. Nonethe-

less, as with all guideline documents, there will

be a need in the future for revision in the light of

new evidence and, more importantly, a concerted

effort to translate the guidelines into practice.

The recommendations are intended to serve as

starting points for clinical decision making, and

it is emphasized that the clinical judgment of the

health care provider must always be included in

the decision-making process and in the applica-tion of these recommendations. They are not to

be considered as rules or standards of clinical

practice, in keeping with the objectives of

KDOQI. It is hoped that the information in this

guideline document and the research recommen-

dations provided will help improve the quality of

care provided to children who have CKD and

will stimulate additional research that will aug-

ment and refine this guideline in the future.

KDOQI is moving into an exciting new phase

of activities. With the publication of theClinical

Practice Guidelines and Clinical Practice Rec-ommendations for Diabetes and Chronic Kidney

Disease in February 2007, KDOQI achieved its

primary goal of producing evidence-based guide-

lines for the 12 aspects of CKD care most likely

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to improve patient outcomes. We now seek to

apply the knowledge acquired in the develop-

ment and refinement of the KDOQI processes to

improve clinical practice through a broader range

of activities that include directed research, public

policy, guideline updates, commentaries on Kid-

ney Disease: Improving Global Outcomes

(KDIGO) guidelines, publication forums, and

new guidelines, if not being addressed by KDIGO

or other guideline developers. We are looking

forward to working with various members of the

kidney health care community regarding these

new and continuing KDOQI activities.

In a voluntary and multidisciplinary undertak-

ing of this magnitude, many individuals make

contributions to the final guideline document. It

is impossible to acknowledge each of these indi-

viduals here, but to each and every one of them, I

extend my sincerest appreciation. This limitation

notwithstanding, the members of the Nutrition in

Children with CKD Work Group and the Meth-

ods Consultants are to be commended for all

their time and effort in reviewing the literature

on pediatric nutrition since the release of the first

nutrition guidelines in 2000 and for providing

this update. Special thanks are given to the

Co-Chairs, Dr Bradley Warady and Dr Donna

Secker, for coordinating the activities of the

Work Group. It is their commitment and dedica-

tion to the KDOQI process that has made this

document possible.

Michael Rocco, MD, MSCE

KDOQI Chair

ForewordS10


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EXECUTIVE SUMMARY

INTRODUCTION

Regular evaluation of nutritional status and

provision of adequate nutrition are key compo-nents in the overall management of children withCKD. The traditional and predominant focus ofnutritional management for children with im-paired kidney function is to prevent the develop-ment of PEM and meet the patients vitamin andmineral needs. More recently, overnutrition char-acterized by obesity and the long-term implica-tions of unbalanced dietary and lifestyle prac-tices are of increasing concern to the pediatricCKD population, and attention to this issue mustbe incorporated into the nutrition management

scheme. Thus, the focus of nutritional care forchildren across the spectrum of CKD must al-ways be centered on the achievement of thefollowing goals:

Maintenance of an optimal nutritional status(ie, achievement of a normal pattern of growthand body composition by intake of appropri-ate amounts and types of nutrients).

Avoidance of uremic toxicity, metabolic abnor-malities, and malnutrition.

Reduction of the risk of chronic morbiditiesand mortality in adulthood.

This publication represents the first revision ofthe K/DOQI Pediatric Clinical Practice Guide-lines for Nutrition in Chronic Renal Failure andis a completely revised and expanded document.The revision of the document published in 2000was considered necessary for the following rea-sons:

To modify prior guideline statements basedupon the availability of information publishedsubsequent to the development of the 2000guidelines.

To expand the target population with recom-mendations to address patients with CKDstages 2 to 5 and kidney transplant recipients,in addition to the dialysis population ad-dressed in the prior publication.

To address a variety of topics not covered inthe original guidelines, such as the dietarymodification of sodium, potassium, fluid, cal-cium, and phosphorus, all of which can have aprofound impact on patient outcomes.

To incorporate references to dietary recommen-dations, anthropometric reference values, andgrowth charts for the healthy population thatreplaced those on which the 2000 guidelineswere based.

To reconcile discrepancies in recommenda-tions for nutrient modification that exist be-tween the pediatric nutrition guidelines andrecent KDOQI guidelines on Hypertensionand Dialysis Adequacy.

One of the challenges for the Work Group inrevising the 2000 K/DOQI Pediatric NutritionGuidelines was the remarkable lack of publisheddata available for the topic of nutrition in chil-

dren with all stages of CKD. In addition, thequality of evidence in pediatric nephrology stud-ies related to the issues addressed in these guide-lines was frequently low due to small samplesize, the lack of randomized controlled trials, andthe lack of information for both short- and long-term clinical outcomes. Thus, the Work Grouphas generated a set of guideline recommenda-tions to provide guidance to practitioners on theclinical aspects of nutrition management while atthe same time recognizing the limited evidencethat exists. These recommendations are based onavailable evidence, such as it exists; they also

rely heavily on the opinion of the Work Groupmembers and are graded accordingly. All submit-ted suggestions from physicians, nurses, anddietitians who participated in the public reviewof the draft recommendations were carefullyreviewed and considered for incorporation intothe recommendations by the Work Group Chairsand individual Work Group members. Most im-portantly, the absence of randomized controlledtrials to support the recommendations made pre-cludes the subsequent development of clinicalperformance measurements by oversight bodies

on most, if not all, of the issues addressed by theguidelines.

The process of revising the guidelines has alsoprovided a unique opportunity to detect andhighlight deficiencies in the scientific literatureand to identify much needed areas of research for

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clinicians and scientists to undertake in the fu-ture. Areas of uncertainty arose for several rea-sons. For some issues, research in the pediatric

CKD population has never been undertaken. Forothers, studies have provided indeterminate re-sults, either because of small sample size orbecause infants, children, and adolescents wereconsidered together, precluding the ability torelate outcomes to specific age groups. Studiesthat are rigorously designed to consider theseissues and more and that address such topics asthe role of inflammation on the nutritional statusof children, the contribution of nutrition manage-ment to modification of cardiovascular risk, andthe impact of frequent hemodialysis (HD) onenergy, protein, and vitamin needs are requiredto ensure that future recommendations are trulyevidence based.

The charge to the Work Group was to developcomprehensive guideline recommendations thatcould provide valuable assistance to all clini-cians (eg, dietitians, physicians, and nurses) in-volved in the nutritional management of childrenwith CKD. We believe we have accomplishedthat goal. Of course, the primary use of theserecommendations is to complementbut not re-placeclinical judgment and to recognize thatthis is a living document that requires regular

modification as new information becomes avail-able. When used in this manner, we are confidentthat the information contained in this documentwill contribute to improved clinical managementand outcomes of children with CKD.

Finally, the Work Group expresses its apprecia-tion to Michael Cheung, Dekeya Slaughter-Larkem, and Donna Fingerhut of the NKF-KDOQI Management Team and to Katrin Uhligand Ethan Balk at the Tufts Center for KidneyDisease Guideline Development and Implemen-tation for their guidance and assistance in the

development of this guideline.

RECOMMENDATIONS

Recommendation 1: Evaluationof Growth

and Nutritional Status

1.1 The nutritional status and growth of all

children with CKD stages 2 to 5 and 5D

should be evaluated on a periodic basis.

(A)

1.2 The following parameters of nutritional

status and growth should be considered in

combination for evaluation in children

with CKD stages 2 to 5 and 5D.(B)i Dietary intake (3-day diet record or

three 24-hour dietary recalls)

ii Length- or height-for-age percentile

or standard deviation score (SDS)

iii Length or height velocity-for-age per-

centile or SDS

iv Estimated dry weight and weight-for-

age percentile or SDS

v BMI-for-height-age percentile or SDS

vi Head circumference-for-age percen-

tile or SDS (


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height-for-age < 3rd percentile), and

potential for linear growth if growth

failure (height velocity-for-age SDS 95th per-

centile) or prehypertension (systolic and/or

diastolic blood pressure > 90th percentile

and< 95th percentile). (B)8.4 Fluid intake should be restricted in chil-

dren with CKD stages 3 to 5 and 5D who

are oligoanuric to prevent the complica-

tions of fluid overload.(A)

8.5 Potassium intake should be limited for chil-dren with CKD stages 2 to 5 and 5D who

have or are at risk of hyperkalemia. (A)

Recommendation 9: Carnitine

9.1 In the opinion of the Work Group, there is

currently insufficient evidence to suggest

a role for carnitine therapy in children

with CKD stage 5D.

Recommendation 10: Nutritional Management

of Transplant Patients

10.1 Dietary assessment, diet modifications,and counseling are suggested for chil-

dren with CKD stages 1 to 5T to meet

nutritional requirements while minimiz-

ing the side effects of immunosuppres-

sive medications.(C)10.2 To manage posttransplantation weight

gain, it is suggested that energy require-

ments of children with CKD stages 1 to

5T be considered equal to 100% of the

EER for chronological age, adjusted for

PAL and body size (ie, BMI).(C)Further

adjustment to energy intake is suggested

based upon the response in rate of weight

gain or loss.(C)

10.3 A balance of calories from carbohydrate,protein, and unsaturated fats within the

physiological ranges recommended by

the AMDR of the DRI is suggested for

children with CKD stages 1 to 5T to

prevent or manage obesity, dyslipide-

mia, and corticosteroid-induced diabe-

tes.(C)

10.4 For children with CKD stages 1 to 5T

and hypertension or abnormal serum

mineral or electrolyte concentrations as-

sociated with immunosuppressive drug

therapy or impaired kidney function,

dietary modification is suggested.(C)10.5 Calcium and vitamin D intakes of at

least 100% of the DRI are suggested for

children with CKD stages 1 to 5T. (C) Inchildren with CKD stages 1 to 5T, it is

suggested that total oral and/or enteral

calcium intake from nutritional sources

and phosphate binders not exceed 200%

of the DRI (see Recommendation 7.1).

(C)

10.6 Water and drinks low in simple sugars

are the suggested beverages for chil-

dren with CKD stages 1 to 5T with highminimum total daily fluid intakes (ex-

cept those who are underweight, ie,

BMI-for-height-age < 5th percentile)

to avoid excessive weight gain, pro-

mote dental health, and avoid exacer-

bating hyperglycemia.(C)

10.7 Attention to food hygiene/safety and

avoidance of foods that carry a high risk

of food poisoning or food-borne infection

are suggested for immunosuppressed

children with CKD stages 1 to 5T. (C)

Executive Summary S15


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RECOMMENDATION 1: EVALUATION OF GROWTHAND NUTRITIONAL STATUS

INTRODUCTION

Normal growth and development are majorgoals of pediatric CKD management. Because

adequate nutritional status is important in achiev-

ing these goals, careful monitoring of nutritional

status is essential. Nutritional status is a complex

concept that cannot be adequately summarized

by a single measurement. Multiple measures,

considered collectively, are required to give a

complete and accurate picture of nutritional sta-tus. Growth parameters are particularly impor-

tant in children and should be accurately mea-

sured using calibrated equipment and

standardized techniques (see Appendix 1).

1.1 The nutritional status and growth of

all children with CKD stages 2 to 5 and

5D should be evaluated on a periodic

basis.(A)

1.2 The following parameters of nutritional

status and growth should be considered in

combination for evaluation in children

with CKD stages 2 to 5 and 5D.(B)

i Dietary intake (3-day diet record or

three 24-hour dietary recalls)

ii Length- or height-for-age percentile

or standard deviation score (SDS)iii Length or height velocity-for-age per-

centile or SDS

iv Estimated dry weight and weight-for-

age percentile or SDS

v BMI-for-height-age percentile or SDS

vi Head circumference-for-age percen-

tile or SDS (


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cent acute changes in medical status or

dietary intake may warrant more fre-

quent evaluation.(C)

RATIONALE

1.1: The nutritional status and growth of allchildren with CKD stages 2 to 5 and 5D shouldbe evaluated on a periodic basis. (A)

1.2: The following parameters of nutritional

status and growth should be considered in com-bination for evaluation in children with CKDstages 2 to 5 and 5D. (B)

Because of the high prevalence of growthretardation in children with CKD, nutrition hasalways been a primary focus of pediatric CKD

care. Early studies emphasized the importance ofadequate energy intake in maintaining normalgrowth in pediatric CKD. However, no studydemonstrated a growth advantage to a caloricintake greater than about 75% of the RDA,2-4

which corresponds approximately to 100% of theEER in children older than 3 months. Interest-ingly, the prevalence of undernutrition in chil-dren with CKD is unknown. This is likely due, inpart, to an inadequate definition of undernutri-tion in this population. In children with CKD, theprevalence of undernutrition has been demon-

strated to vary widelyfrom 2% to 65%depending on the definition used.5 In the generalpopulation, the World Health Organization(WHO) has defined undernutrition as weight-for-age, height-for-age, and weight-for-height 2 SDsor greater less than the Centers for DiseaseControl and Prevention (CDC) reference me-dian,6 in recognition of the fact that long-termundernutrition may lead to wasting (low weight-for-height) and/or stunting (low height-for-age).However, this definition may be inappropriate inchildren with CKD. Whereas stunting can bereasonably attributed solely to long-term under-nutrition in otherwise healthy children, the multi-factorial cause of stunting in children with CKDmakes it a poor choice as a definition of undernu-trition in this group. In the CKD population,anthropometric definitions of undernutrition arecomplicated; consideration must be given to theappropriateness of measures for both age andheight of the child.

Body composition has yet to be well character-ized in pediatric CKD. Few high-quality studies

are available in which measures of body compo-

sition were adequately adjusted for height andappropriately compared with a healthy reference

population.

7-12

Of these, lean mass deficits wereobserved in some studies,11 but not others.7 Fat

mass appears to be increased relative to height in

children with CKD.11 Preliminary evidence in

small numbers of children suggests that use of

growth hormone may result in lower fat mass

and higher lean mass for height.11

Interpretation of many prior studies of nutri-tion and growth in pediatric CKD is difficult

because most studies considered infants and older

children together as a uniform group. There are

reasons to believe that infants younger than 2 to

3 years behave very differently from older chil-dren. At a theoretical level, there are 2 main

considerations. First, a much larger proportion of

the daily energy requirement is devoted to growthin infants compared with older children. Second,

growth is driven primarily by nutrition during

infancy, whereas growth hormone and sex hor-

mones have a dominant influence during child-

hood and adolescence, respectively.13-16 On a

practical level, there is evidence to support the

notion that infants and older children behave

differently. Inadequate spontaneous calorie in-

take has been clearly demonstrated in infantswith CKD17-19; energy intakes for older children

usually are normal relative to body size.9 In

studies separating children by age, weight-for-

height indices, and BMI-for-age, z scores werelow in younger children, but normal in older

children.10,12 Lean mass deficits were also more

likely in younger than older children.7,8,10 Rou-

tine calorie and/or protein supplementation have

been shown to improve growth in infants with

CKD.17-19 However, there is no clear evidence

that routine nutritional supplements have a simi-

lar effect in older children.Because of these differences between infants

and older children, the present recommendationsemphasize the importance of considering the age

of the child when planning nutritional monitor-

ing and interventions.

Historically, the main focus of malnutrition in

children with CKD has been undernutrition; there

is some evidence that obesity is beginning to be a

problem in the CKD population.20-22

Evaluation of Growth and Nutritional Status S17


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Dietary Intake

It is suggested that dietary intake be assessedregularly by a skilled registered dietitian by

means of a 3-day diet diary. Three 24-hour re-calls may be preferable in adolescents. Dietaryintake data provide useful information about thequantity and quality of nutrients ingested. The 2most practical and clinically feasible ways todetermine usual daily intake are the prospective3-day dietary diary and the retrospective 24-hourdietary recall. From either of these, daily intakeof calories, macronutrients (carbohydrate, pro-tein, and fat), vitamins, and minerals can beestimated. Each of the methods has its ownlimitations. Dietary diaries have been shown to

give unbiased estimates of energy intake in nor-mal-weight children younger than 10 years; how-ever, underreporting is common in adoles-cents.23,24 Twenty-fourhour recalls may be bettersuited to adolescents. The most important limita-tion of the 24-hour recall method is its poorability to capture the day-to-day variability indietary intake. Children may be even more sus-ceptible to this limitation than adults becausethey tend to have more day-to-day variability.25

It may be useful to obtain three 24-hour recalls tomore completely evaluate the food-intake pat-tern. One weekend day should be included in a3-day diet diary and as 1 of three 24-hour recalls.Despite their limitations, dietary recall inter-views conducted by a skilled pediatric registereddietitian or dietary diaries completed by thepatient and/or parent as instructed by a registereddietitian provide useful general information aboutthe pattern of food intake. Information aboutdietary intake allows the treating team to evalu-ate the adequacy of a patients intake beforesignificant adverse changes in body compositionresult.

Poor intake is expected in infants with CKD

and should prompt immediate initiation of nutri-tional supplements if there is any evidence ofinadequate weight gain or growth. When sponta-neous intake is low in a poorly growing olderchild, consideration also must be given to thepossibility that the poor intake is a result of thepoor growth, rather than the cause. Spontaneouscalorie intake increased by almost 12% in a studyof 33 children with CKD during treatment withrhGH.26

Length- or Height-for-Age Percentileor SDS

Length (infants 2 years) or height (chil-dren 2 years) should be measured regularly,

plotted on the length- or height-for-age curves,and the percentile and/or SDS should be calcu-lated(Appendix 2,Table 32). Growth retardationis common in CKD.2,3,12,27,28 The impact ofCKD on growth depends on both the degree ofkidney impairment and age of the child. Normalgrowth can be divided into 3 phases: infancy(dominated by nutrition), childhood (dominatedby growth hormone), and puberty (dominated bysex hormones).13 The infancy phase normally isreplaced by the childhood pattern between 6 and12 months of age. In CKD, onset of the child-

hood phase frequently is delayed until 2 to 3years of age or interrupted by a transient resump-tion of the infancy pattern.13 CKD also results ina delay in the onset of pubertal growth, as well asa shorter pubertal growth spurt.29 Together, thesealterations to the normal pattern of growth maylead to severe short stature. The typical CKDgrowth pattern is characterized by decreasedgrowth velocity during infancy, followed by nor-mal growth velocity during childhood and im-paired growth velocity again during adoles-cence.16 However, growth velocity also may below during the childhood phase in children withCKD stages 4 or 5.3,30 Numerous factors mayinfluence growth in CKD, including acidosis,31

disturbances in the growth hormone axis,32 andpoor nutritional intake.2 Nutritional intake has itsgreatest influence during the infancy phase ofgrowth.16

Length (infants) should be measured by usinga length board, and height (older children), byusing a wall-mounted stadiometer, preferably bythe same well-trained person at each assessment.Calculating the SDS or plotting the childs heighton the normal growth chart to determine the

percentile allows comparison with healthy chil-dren. In 2000, the CDC published revised NorthAmerican growth reference charts for infants andchildren up to 20 years of age(Figs 11to 14).33

In 2006, the WHO released new growth stan-dards for children from birth to 5 years of age(Figs 1 to 10).34 These growth standards aredistinguished from the CDCreferencecharts in 2important ways. First, the children contributingto the WHO Growth Standards were specifically

Recommendation 1S18


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selected to represent children growing underideal conditions: they had nonsmoking mothers,were from areas of high socioeconomic status,

and received regular pediatric health care, includ-ing immunizations. A subset of 882 infants, allbreastfed for at least 4 months, provided longitu-dinal data for 24 months. Second, the studypopulation was of broad ethnic diversity; partici-pants were recruited from Brazil, Ghana, India,Norway, Oman, and the United States. Impor-tantly, ethnicity had very little impact on growth,indicating that the growth standards reflect areasonable expectation for growth regardless ofethnicity; only 3% of the variability in growthwithin the population could be attributed to coun-try of origin.34

Because the WHO Growth Standards repre-sent ideal growth and ideal growth should be thegoal for children with CKD, the WHO GrowthStandards should be used as the reference forchildren from birth to 2 years. Differences be-tween the CDC reference curves and the WHOGrowth Standards are minimal after 2 years. Forthis reason and because the switch is made fromlength to height measurement at 2 years, 2 yearsappears to be a reasonable age to make thetransition from the WHO Growth Standards tothe CDC reference curves (www.rcpch.ac.uk/

doc.aspx?id_Resource2862; last accessed Oc-tober 23, 2008).

It may be useful to consider the genetic heightpotential of the child when assessing adequacyof growth. Although the exact contribution ofheredity cannot be calculated, an estimate of achilds adult height potential can be made bycalculating midparental height adjusted for thesex of the child. Midparental height is calculatedas follows (see Appendix 2, Table 33 for anonline calculator):

Girls: 5 inches (13 cm) is subtracted from the

fathers height and averaged with the mothersheight;

Boys: 5 inches (13 cm) is added to themothers height and averaged with the fathersheight.

The midparental height is plotted on the growthchart (of the same gender as the child) at 20 yearsof age. For both girls and boys, 3.5 inches (8.5cm) on either side of this calculated value (targetheight) represents the 3rd to 97th percentiles for

anticipated adult height.35 The 5 inches (13 cm)represents the average difference in height ofmen and women; thus, the child grows, on aver-

age, to the midparental height percentile.Adequate growth is a good indication of ad-equate nutrition over the long term. However,acute weight loss may be severe and alterationsin body composition may be substantial beforelinear growth is impaired. Growth usually contin-ues at a normal rate in malnourished childrenuntil significant wasting occurs.36 For this rea-son, additional measures of nutritional status areadvised.

Lengthor Height Velocity-for-Age Percentileor

SDS

The growth velocity (change in height per unitof time) can be determined by recording serialheight measurements. In children younger than 2years, the change in length percentile and/or SDSwill give an idea of growth velocity (a negativechange indicates poor growth; a positive changemay represent catch-up growth). Calculation ofgrowth velocity percentile and/or SDS for chil-dren younger than 2 years can be done by usingdata from the 2006 WHO Growth Standards.Height velocity percentile and/or SDS can becalculated for children older than 2 years by

using reference data from the Fels LongitudinalStudy.37 It is important to recognize that heightvelocity cannot be accurately assessed for inter-vals shorter than 6 months in those older than 2years. However, more frequent height measure-ments allow a running look at growth and give ageneral impression of its adequacy.

Estimated Dry Weight and Weight-for-Age

Percentileor SDS

Euvolemic weight should be determined regu-larly. The weight should be plotted on the weight-for-age curves, and the percentile and/or SDSshould be calculated. Weight is an important partof any nutritional assessment. In CKD, it isimportant to ensure that weight is measured in aeuvolemic state. This generally is referred to asdry weight because fluid overload is commonin those with CKD stage 5. Children with chronicnephrotic syndrome also may have fluid over-load, even at milder stages of CKD. Fluid over-load will influence not just weight, but also mayaffect other anthropometric measures, such as

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arm circumference and skinfold thicknesses.38,39

Volume depletion also may be present in someconditions resulting in pediatric CKD (dysplasia,

obstructive nephropathy, and cystinosis). It isequally important that the euvolemic weight beconsidered in these cases. The estimated dryweight can be challenging to ascertain becauseweight gain is expected in growing children.Five parameters are helpful in the estimationprocess: weight, presence of edema, blood pres-sure, certain laboratory values, and dietary inter-view. The midweek postdialysis weight and thecombination of noninvasive blood volume moni-toring and the postdialytic vascular compartmentrefilling rate are used for evaluation purposes inan HD patient.40 The weight at a monthly visit

(minus dialysis fluid in the peritoneal cavity) isused for the child on PD therapy. The estimateddry weight is challenging to evaluate in patientsprone to edema and must be done in conjunctionwith a physical examination. Excess fluid may bevisible in the periorbital, pedal, and other regionsof the body. Hypertension that resolves withdialysis can be indicative of excess fluid weight.Other responses to dialytic fluid removal, such ascramping or hypotension, may also give cluesabout the fluid status of the patient. Decreasedserum sodium and albumin levels may be mark-

ers of overhydration. Rapid weight gain in theabsence of a significant increase in energy intakeor decrease in physical activity must be evalu-ated critically before it is assumed to be dryweight gain.

After the dry weight has been determined, itshould be used to calculate the BMI and deter-mine the weight-for-age percentile and/or SDS(or be plotted on the weight-for-age curves). Asnoted in the section on height, the 2006 WHOGrowth Standards should be used as the refer-ence for children up to 2 years; the 2000 CDCgrowth charts should be used for children olderthan 2 years. It is important to recognize that theweight-for-age SDS is not particularly useful inisolationweight-for-age will be low in growth-retarded children. Rather, it should be interpretedin the context of the height-for-age SDS.

BMI-for-Height-Age Percentileor SDS

It is suggested that BMI be determined eachtime height and weight are measured. BMI shouldbe plotted on the sex-specific BMI-for-age curves,

and the percentile and/or SDS should be calcu-lated. BMI is an accepted and easily calculatedmethod of evaluating weight relative to height.

However, BMI, calculated as weight (kg) di-vided by height (m) squared is not completelyindependent of either age or height. This isexplained in part by age-related changes in bodyproportions and in part by mathematics: a 1-di-mensional measure (height) will predict a 3-di-mensional measure (increasing weight repre-sents body growth in 3 dimensions) to the thirdpower, not the second power.41 The solution hasbeen to express BMI relative to age in develop-ing children.42 In this relation, age functions as asurrogate for both height and maturation. Be-cause height, age, and maturation are highly

correlated in healthy children, this approachworks reasonably well. Sex-specific BMI-for-age reference data permit calculation of BMI-for-agez scores or percentiles, allowing meaningfuland consistent interpretation of BMI in normalchildren regardless of age. In children with kid-ney disease, in whom growth retardation anddelayed maturation are common, this approachhas limitations. Expressing BMI relative to chro-nological age in a child with growth and/ormaturational delay will result in inappropriateunderestimation of his or her BMI compared

with peers of similar height and developmentalage. To avoid this problem, it may preferable toexpress BMI relative to height-age in childrenwith CKDthat is, the age at which the childsheight would be on the 50th percentile.38,523 Thisapproach ensures that children with CKD arecompared with the most appropriate referencegroup: those of similar height and maturation.

Height-age is believed to provide a reasonablesurrogate for maturation in most children (ie, theage at which a child would be at the 50th percen-tile for height likely is close to the age at whichmost healthy children would have a similar levelof sexual/physical development). Similarly, inchildren with short stature, expressing BMI rela-tive to height-age will minimize errors that mayoccur as a result of the correlation betweenBMI-for-age and height-for-age. However, cau-tion must be used in applying this approach tochildren outside the pubertal or peripubertal pe-riod, for whom the correlation between height-age and maturation is less clear. BMI relative tochronological age may be more logical in some

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cases, particularly when sexual maturation iscomplete.

Although the weight-for-height index is a mean-

ingful measure during early and midchildhood,BMI has the advantageof being applicable through-out the lifespan, from infancy to adulthood, and isbecoming the standard method of assessing weightrelative to height.43 While BMI-for-age charts arenow available from birth onwards, clinical experi-ence in using and interpreting BMI before 24months of age is limited, as are data on its associa-tion with current or future morbidity and for thisreason, BMI is suggested rather than weight-for-height index after the age of 2 years.

The CDC defines underweight as a BMI-for-age less than the 5th percentile (www.cdc.gov/

nccdphp/dnpa/growthcharts/training/modules/module1/text/page5a.htm; last accessed February1, 2008).44 A BMI-for-age greater than or equalto the 85th percentile is considered overweight,and greater than the 95th percentile, obese.45 TheWHO definitions of underweight differ some-what from those used by the CDC. A BMI-for-age SDS of2.0 (BMI-for-age 3rd percen-tile) recently has been proposed as a cutoff todefine underweight or thinness in children.This definition is attractive because it corre-sponds to the cutoff for grade 2 thinness in adults

(BMI, 17 kg/m2

).43

However, no high-qualitystudies are available linking BMI less than acertain cutoff to poor outcomes in the generalpopulation. Therefore, no evidence-based defini-tions of undernutrition or thinness exist. Fur-thermore, the applicability of such definitions tothe CKD population is unknown. Two largestudies of adult HD patients demonstrated aninverse relationship between BMI and mortalityrisk, with no clear BMI threshold above whichthe risk stabilized or began to increase; mortalityrisk continued to decrease even as BMI in-creased to greater than 30 kg/m2.46,47 A smallerstudy of adult HD patients suggested increasedmortality risk with BMI less than 17 and BMIgreater than 23 kg/m2 compared with those withBMI between 17.0 and 18.9 kg/m2.48 In childrenwith stage 5 CKD, a U-shaped association wasdemonstrated between BMI-for-age SDS andmortality risk. Children with a BMI SDS eithergreater or less than 0.50 had a greater risk ofmortality than those with a BMI SDS of 0.5;each 1.0-SD unit difference in BMI SDS was

associated with a 6% greater risk of mortality.49

It is important to recognize that this study onlydemonstrated an association between BMI and

mortality, but could not establish a causal relation-ship. Furthermore, the additional mortality riskassociated with BMI SDS greater or less than 0.5was small.

Interpretability of BMI may be limited in theCKD population due to fluid overload. Clearly,any excess fluid will artificially increase BMI.Fluid overload representing 10% of the bodyweight will result in a BMI SDS approximately0.5 to 1.0 SD units greater than what it would beat dry weight. Therefore, efforts should be madeto use only a true dry weight when calculatingBMI.

High-quality reference values for BMI rela-tive to age are now available throughout child-hood. The 2000 CDC revised growth chartsinclude sex-specific BMI-for-age curves for chil-dren and adolescents between 2 and 20 years ofage.33 These curves, developed using a NorthAmerican population, provide a contemporaryBMI reference that recognizes the dependence ofBMI on age and allow calculation of BMI-for-age SDS and percentiles. The 2006 WHO GrowthStandards also include BMI standards for chil-dren from birth to 5 years of age (www.who.

int/childgrowth/standards/technical_report/en/index.html; last accessed October 23, 2008).34

Together, the WHO Growth Standards and theCDC growth charts provide reference values forBMI from birth to adulthood. As for length andheight measures, BMI should be compared withthe WHO Growth Standards up to 2 years of ageand with the CDC growth charts thereafter (www.rcpch.ac.uk/doc.aspx?id_Resource2862; lastaccessed October 23, 2008).

Head Circumference-for-Age Percentileor SDS

Head circumference should be measured regu-larly in children 3 years and younger. Headcircumference should be plotted on the headcircumference-for-age curves. Poor head growthis well documented in children with CKD,50,51

with infants at highest risk. Although no studieshave specifically related head circumference tonutritional status in CKD, regular measurementsof head circumference in conjunction with inter-mittent developmental assessments are an impor-tant part of routine pediatric CKD care. The 2007

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WHO Growth Standards should be used as areference.52

NormalizedProtein Catabolic Rate

PEM may have profound effects on growthand development and may be associated withincreased risk of morbidity and mortality.

Protein catabolic rate (PCR) has been studiedas an objective measure of DPI in stable patientsreceiving maintenance HD. PCR can be normal-ized to a patients weight (nPCR); nPCR initiallywas studied in the 1980s as a marker of DPI inpediatric HD patients assumed to be in stablenitrogen balance.53 Calculation of nPCR is basedupon the increase in blood urea nitrogen (BUN)level from the end of 1 HD treatment to thebeginning of the next treatment to calculate theurea generation rate (G; mg/min). nPCR origi-nally was calculated by using formal urea kineticmodeling in association with Kt/V calcula-tions.54 Recent pediatric data demonstrate thatalgebraic formulas yield nearly identical nPCRresults compared with formal urea kinetic model-ing.55 The algebraic nPCR calculation is as fol-lows:

G (mg min) [(C2V2) (C1V1)]t

where C1 is postdialysis BUN (mg/dL), C2 ispredialysis BUN (mg/dL), V1 is postdialysistotal-body water (dL; V1 5.8 dL/kg postdi-alysis weight in kg), V2 is predialysis total-bodywater (dL; V2 5.8 dL/kg predialysis weightin kg), and t is time (minutes) from the end of thedialysis treatment to the beginning of the follow-ing treatment.

Then, nPCR is calculated by using the modi-fied Borah equation56:

nPCR 5.43 estG V1 0.17

where V1 is total-body water (L) postdialysis(0.58 weight in kg).

Data from adult studies demonstrate that thepre- and postdialysis BUN levels from the sametreatment can be used to calculate nPCR; addi-tional blood sampling from the next treatment isnot necessary.57 Recent pediatric data demon-strated increases in nPCR in malnourished chil-dren on HD therapy who received IDPN. In thesestudies, higher nPCR was associated with subse-

quent weight gain, whereas lower nPCR pre-dicted future weight loss in adolescents.58,59

Comparison of nPCR versus serum albumin

level in an entire single-center population, irre-spective of nutrition status, showed that nPCRless than 1 g/kg/d of protein predicted a sustainedweight loss of at least 2% per month for 3consecutive months in adolescent and youngadultaged patients,60 whereas serum albuminlevels could not. In younger pediatric HD pa-tients, neither nPCR nor serum albumin levelwas effective in predicting weight loss. Thispotentially could be explained by: (1) betternutritional status in infants and toddlers who aremore likely to be tube fed, (2) a greater contribu-tion of unmeasured urine urea clearance, (3)

differences in protein catabolism, and/or (4) dif-ferent growth rates in younger children com-pared with older children. It is also possible thatbecause nPCR was derived in adult patientsreceiving HD, nPCR may be a valid measureonly for patients of adult age or size.

Although no data exist to guide recommendedoptimal nPCR measurement frequency in HDpatients, the same data needed for Kt/V calcula-tion allow for nPCR calculation without addi-tional blood sampling. Thus, nPCR can be moni-tored monthly along with Kt/V to follow up

trends for a particular patient and provide anobjective measure of protein intake.61 TheK/DOQI Adult Nutrition Guidelines recommendmonthly assessment of nPCR for maintenanceHD patients.62 It is suggested that nPCR level betargeted to the age-specific protein intake guide-lines noted in Recommendation 5.

In a manner similar to the evaluation of nPCRin patients receiving HD, it is recommended thatthe DPI of adults receiving PD be estimatedseveral times per year by determination of theprotein equivalent of nitrogen appearance(PNA).63 This is calculated by measuring theurea nitrogen content of urine and dialysate,which represents the total nitrogen appearance(TNA), and multiplying that value by 6.25 (thereare 6.25 g of protein per 1 g of nitrogen).64

Although limited data for this subject are avail-able in pediatrics and the assessment is notregularly carried out in pediatric dialysis centers,Mendley and Majkowski65 defined the relation-ship between urea nitrogen and TNA in childrenundergoing PD as follows:

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TNA (gd) 1.03 (urea nitrogen appearance)

0.02 (weight in kg) 0.56

(for subjects age 0 to 5 years)

or 0.98 (for subjects age 6 to 15 years)

Patient age was taken into consideration be-cause of its relationship to dialysate protein loss.

Edefonti et al66 later reported that incorporat-ing dialysate protein nitrogen and body surfacearea (BSA) in the formula could improve theprediction of TNA. Their recommended formulais as follows:

TNA (gd) 0.03 1.138 urea-Nurine

0.99 urea-Ndialysate 1.18 BSA

0.965 protein-Ndialysate

Limitations of PNA are that it is valid onlywhen the patient is not anabolic or catabolic, thevalue changes rapidly when DPI is altered andthus may not reflect usual protein intake, and itshould be normalized for patient size, althoughthe best parameter to use has not been deter-mined. In adults, normalization to ideal weight isrecommended.

OtherMeasures Considered

Serum albumin: Serum albumin was recom-mended in the 2000 K/DOQI Nutrition Guidelinesas a marker of nutritional status. Hypoalbuminemiais a common finding in those with CKD and consis-tently has been associated with increased mortalityin both adults46,67-69 and children with CKD.70

Because PEM may lead to hypoalbuminemia, se-rum albumin level generally has been considered auseful index of nutritional status. However, impor-tant limitations have been identified with respect tothe ability of serum albumin level to function as areliable marker of malnutrition in the setting ofCKD.38,71-77 Serum albumin is depressed in the

setting of both systemic inflammation and volume-overload states.73,74 In the absence of inflammatorymarkers, hypoalbuminemia is not predictive of in-creased mortality.77 Given the association of hy-poalbuminemia with mortality, it remains an impor-tant component of the general evaluation of patientswith CKD. However, the value of albumin as amarker of nutritional status is questionable. Hy-poalbuminemia should lead to careful assessmentof volume status and protein loss and to investiga-tion for causes of systemic inflammation.

Mid-armanthropometry: Mid-armcircumference(MAC) and triceps skinfold thickness (TSF) previ-ously were recommended as part of the nutritionalassessment in pediatric CKD.62 TSF was consid-ered to reflect total fat mass, and the combination ofTSF and MAC were used to calculate the mid-armmuscle circumference (MAMC) and mid-armmuscle area (MAMA), which are purported toreflect total muscle mass. These measures are nolonger recommended as a part of routine assess-ment. There are 4 main problems with the use ofthese measures.

First, it is difficult to obtain reliable measure-ments, particularly in patients with CKD. Skin-fold thickness measurement is extremely opera-tor dependent and lacks precision, except in very

experienced hands.78

In children with CKD, thepresence of fluid overload may result in overesti-mates and poor reliability of skinfold thick-ness.38 MAC is easier to reliably measure thanTSF, but is even more susceptible to overestima-tion due to fluid overload.38,39

Second, it is not clear that MAMC and MAMAare accurate reflections of total muscle mass,even in otherwise healthy individuals.38 The rela-tionship between total muscle mass and MAMCor MAMA is even less clear in those with CKD.Abnormal regional distribution of lean tissue in

patients with CKD

79

may result in a breakdownin the relationship between MAMC or MAMAand total muscle mass. Furthermore, the poten-tial errors associated with TSF and MAC due tofluid overload and distorted fat and lean distribu-tion may be compounded when they are com-bined in equations to calculate MAMC andMAMA. Arm measures failed to reliably detectdecreased lean mass as measured by using invivo neutron activation analysis in at least 1study of adult HD patients.80

Third, deficits in these parameters have neverbeen described convincingly in children withCKD. Although arm measures have been re-ported to be low relative to age in prior studies ofchildren with CKD, there is little evidence thatdeficits exist when appropriate adjustments weremade for short stature. Given that children withCKD are often short for age, proportionallysmaller arm circumferences and skinfold thick-nesses are expected. Arm measures would beexpressed more appropriately relative to heightor height-age. When this has been done, deficits



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have been rare. In only 1 pediatric study in whichTSF was adjusted appropriately for height weresignificant deficits in TSF seenand only in

younger children.

12

The mean TSF-for-height-age z score was high at 0.9 in a study of 56children with CKD.5 There is growing evidencethat TSF and total fat mass are high relative toheight in the CKD population. Mean total fatmass (determined by using dual-energy X-rayabsorptiometry [DXA]) for height-age z scorewas 1.1 in 50 children with CKD stages 3 to5.11 One study of PD patients found mean MAC-for-height-age z scores of 1.1 in 12 childrenyounger than 10 years and 0.1 in 12 childrenolder than 10 years.12 However, another study of56 children with CKD stages 3 to 5 found a mean

MAC-for-height-agezscore of0.4.5

Finally, few studies have investigated the linkbetween TSF, MAC, MAMC, or MAMA andoutcome in the CKD population. MAMC failedto be identified as an independent predictor ofmortality in a 3-year longitudinal study of 128adult HD patients.68

Dual-energyX-rayabsorptiometry(DXA): A whole-body DXA scan provides excellent estimates of fatmass and lean mass.81 The main limitation of DXAin patients with CKD is that it is unable to distin-

guish normally hydrated from overhydrated leantissue; thus, it may overestimate lean mass in vol-ume-overloaded subjects. DXA has been used ex-tensively for body-composition assessment in adultswith CKD and in several small studies of childrenwith CKD.11,82-86 Although deficits in lean massrelative to height-age have been demonstrated inchildren with CKD,11 there are insufficient data tosupport a recommendation for regular DXA scansin children with CKD. The added value of a DXAscan over such a simple and inexpensive measureas BMI has yet to be proved. Significant advantagesassociated with the extra information provided by

DXA would need to be clearly demonstrated tojustify the expense.

Bioelectricalimpedanceanalysis(BIA): BIA allowsestimation of body fluid compartment volumes,which may then be used to make inferences aboutbody composition.87 However, despite extensiveBIA studies, investigators have been unsuccessfulat developing broadly applicable BIA methods thatfunction well on the individual level.88-93 Marginsof error are so large as to render results of dubious

clinical value.Abnormalities in volume status prob-ably are the biggest problem limiting the interpret-ability of BIA measures in children with CKD. AllBIA measures, including impedance and phaseangle,94-96 will change when either fluid status, fatmass, or lean mass changes. However, it is impos-sible to distinguish which change has occurredbased on BIA measures.

Single-frequency whole-body BIA has beenused in an effort to predict total-body water inchildren receiving maintenance dialysis.93 TheBIA-derived total-body water estimates werecompared with total-body water measured bymeans of isotope dilution (gold standard). Al-though the group mean total-body water mea-sured by using bioimpedance was within 170 mL

of that measured by using isotope dilution, limitsof agreement were wide (17% of the truevalue). This means that an individual subjectwith a true total-body water volume of 30 Lcould be estimated to have a total-body volumeas high as 35.1 L or as low as 24.9 L by usingBIA.

Multiple-frequency BIA (bioimpedance spec-troscopy) allows direct estimation of both extra-cellular fluid (ECF) and intracellular fluid vol-umes,97 although estimates of ECF volumes aremore accurate.98 A small study of children with

mild-to-moderate chronic renal insufficiency usedwhole-body bioimpedance spectroscopy to suc-cessfully estimate ECF volume within 6% of thatmeasured by using isotope dilution.91 Bioimped-ance spectroscopy is a promising technique, par-ticularly for estimating ECF, but it has not yetbeen adequately validated in children or adultswith CKD.

Whole-body BIA has significant limitationswhen abnormalities in fluid distribution exist.The technique is insensitive to large changes influid volume in the trunk and very sensitive tosmall changes in the limbs.99 To avoid this prob-lem, a segmental bioimpedance technique hasbeen developed in which each of 5 body seg-ments (2 arms, 2 legs, and trunk) are measuredseparately.99 In an effort to avoid overrepresenta-tion of the limbs and underrepresentation of thetrunk in the final total-volume calculation, imped-ance from each segment is given appropriateweight; this accounts for the different contribu-tions of each segment to total resistance.99 Thistechnique may be particularly useful in fluid-

Recommendation 1S24


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overloaded persons. However, it has not beenvalidated in children.

A final potential application of BIA is to help

determine whether an individual is euvolemic.Although promising techniques have been devel-oped in this regard,100,101 these methods havenot yet been tested in children.

Multiparameter nutritional assessment scales: Be-cause no single parameter has been found that willidentify all patients at nutritional risk, multiparam-eter indices of nutritional status have been devel-oped in attempts to improve accuracy. Multi-itemmeasures may increase reliability, scope, and preci-sion compared with 1 individual objective measure.

One such index was developed specifically for

children on PD therapy.102,103

Anthropometricand bioimpedance measures were combined togenerate a score; however, the means by whichthe parameters were combined to arrive at a finalscore has limited justification and many of thecomponent measures are highly correlated. Fur-thermore, the score is heavily influenced bysingle-frequency BIA measurements, which areof questionable value. The method does notappear practical for routine clinical practice.

Subjective Global Assessment (SGA), a methodof nutritional assessment using clinical judgmentrather than objective measures, has been widelyused to assess nutritional status of adults withCKD104 for both clinical and research purposes.The clinician performing SGA considers 5 featuresof a medical-nutrition history (weight loss, dietaryintake, gastrointestinal symptoms, functional capac-ity, and metabolic stress) and 4 features of a physi-cal examination (subcutaneous fat loss, musclewasting, edema, and ascites) to assign the patientan overall rating of well nourished, moderatelymalnourished, or severely malnourished withoutadhering to any kind of rigid scoring system.105,106

An SGA specifically for the pediatric population

recently has been developed and validated in chil-dren undergoing major surgery.107 Applicability ofthis pediatric Subjective Global Nutrition Assess-ment (SGNA) in children with CKD is currentlybeing studied.

Frequencyof Assessment

1.3: It is suggested that the frequency ofmonitoring nutritional and growth parametersin all children with CKD stages 2 to 5 and 5D be

based on the childs age and stage of CKD. (C)

In general, it is suggested that assessments be

performed at least twice as frequently as they

would be performed in a healthy child of thesame age. (C) Infants and children with poly-

uria, evidence of growth delay, decreasing or

low BMI, comorbidities influencing growth or

nutrient intake, or recent acute changes in

medical status or dietary intake may warrant

more frequent evaluation. (C)

The frequency with which a nutritional evalu-ation should be conducted depends on both theage of the child and the severity of CKD (Table1). Current recommendations for measurementof growth parameters in healthy infants andchildren vary slightly by country. In general, 2assessments are recommended in the first month,then monthly until 2 months of age, every 2months until 6 months of age, every 3 monthsuntil 18 months of age, every 6 months until 2years of age, and then yearly thereafter.108,109

Given that nutritional intake and growth maybe impaired even with mild CKD in infantsand that these improve with nutritional supple-mentation17,18,110,111it is suggested that growthparameters be monitored at least twice as fre-quently in infants with moderate CKD as isrecommended for healthy infants. More frequentevaluations are required in infants with severeCKD (stages 4 to 5 and 5D). Early recognition ofgrowth delay in infancy is crucial because growthfailure in this critical period is extremely difficultto catch up later.16,30 Any evidence of retardedgrowth in an infant should prompt detailed di-etary assessment and intervention.

In older children, the impact of CKD on growthand body fat and lean stores appears to depend to alarge degree on the severity of CKD. A dose-response relationship between glomerular filtra-tion rate (GFR) and BMI-for-agez score was noted

in 1 study, with lower GFR associated with lowermean BMI-for-agez score.28Again, given the risksof growth retardation in children with CKD, assess-ment of growth parameters is suggested to beperformed at a minimum of every 6 months inchildren with CKD stages 2 to 3, ie, at least twice asoften as recommended for healthy children. Forchildren with more advanced CKD (stages 4 to 5and 5D), more frequent evaluation may be war-ranted due to the greater risk of abnormalities.



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Every effort should be made to conduct nutritionalstatus assessments when the child is euvolemic.

These recommendations represent the mini-

mum intervals for assessment. More frequentevaluation may be warranted in children withevidence of growth delay, decreasing or lowBMI, any comorbidities potentially influencinggrowth or nutrient intake, or recent acute changesin medical status or dietary intake. Three-dayfood records at intervals more frequent thanevery 3 to 6 months are not required for infantsor children with good appetites, grossly adequatedietary intakes, and adequate weight gain. Morefrequent records are indicated when there isconcern about the adequacy of a childs intake oroverconsumption of 1 or more nutrients.

COMPARISON TOOTHER GUIDELINES

The Caring for Australasians with Renal Impair-ment (CARI) CKD Guidelines recommend assess-ment of dietary intake, height/length, weight, headcircumference, and BMI at 1- to 3-month intervalsand suggest that determination of SDS for theanthropometric measures is preferable to simplyplotting on the percentile curve. They also suggestexpressing BMI relative to height-age rather thanchronological age. MAC and TSF are not recom-mended by CARI due to a lack of evidence support-ing their use. The use of nPCR is not advocated forin the CARI nutrition guidelines, although theseguidelines were established before many of therecent studies cited were published.

The European ad hoc Committee on Assess-ment of Growth and Nutritional Status in Perito-neal Dialysis recommends a nutritional assess-ment, including height/length, weight, headcircumference, MAC, and BMI, at a minimuminterval of every month in children younger than5 years and every 2 months for older children.TSF is not recommended due to poor reliability.

They suggest assessment of dietary intake atleast every 6 months and more frequently ininfants. Caution is advised in interpreting serumalbumin levels due to their poor reliability inindicating undernutrition. DXA is considered anonessential measurement tool; it is suggestedno more often than yearly. BIA also is considered

nonessent

guideline nutrisi ckd anak

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